Current Status and Controversy Surrounding Trauma Care in the Elderly: A Collective Review
Current Status and Controversy Surrounding Trauma Care in the Elderly: A Collective Review
Authors: William F. Fallon, Jr., MD, MBA, FACS, Chief, Division of Trauma, Summa Health System, Akron City Hospital, Akron, Ohio; Rebecca E. Duncan, BA, Northeastern Ohio Universities College of Medicine, Rootstown, Ohio.
Peer reviewer: Ian Grover, MD, FACEP, Assistant Clinical Professor of Medicine, Department of Emergency Medicine, UCSD Medical Center, San Diego, California.
Geriatric common is increasingly encountered in the emergency department, and based on current statistics will continue to increase as a percentage of trauma care rendered. Geriatric trauma patients have unique physiologic features and require careful assessment to identify subtle signs of injury. Standard trauma triage guidelines need to include patient's age as a risk factor for more severe injury. Early identification and transfer of an elderly patient may significantly improve both morbidity, including functional outcome and mortality. This articles provides an overview of geriatric trauma, with an emphasis on the unique features of the elderly trauma patient.
The Editor
Introduction
The elderly represent a unique group of patients requiring care after an injury. Elderly trauma patients experience higher overall mortality rates, longer hospital stays, and greater morbidity than younger patients who are injured, even with lower overall injury severity. There also is a significant negative impact from associated co-morbid medical conditions, as well as a greater risk of care-related complications.
Studies show that the fastest growing subset of the elderly trauma population is octogenarians; defined as those age 80 and older. One review of geriatric trauma demonstrated that octogenarians had higher mortality than other elderly trauma patients, despite lower overall injury severity scores.1 Cardiovascular disease was the most frequently encountered pre-existing medical condition in both groups, although octogenarians had higher incidences of congestive heart failure, as well as hematologic disorders, neurologic disorders, and dementia. Diabetes, obesity, and pulmonary complications were more commonly seen in the non-octogenarian patients. The rate of complications found during hospital stays was comparable for both groups of elderly trauma patients. Pulmonary and infectious complications were the most common complications encountered in both groups.
Elderly trauma patients spend more time in the hospital and ICU (intensive care unit) than non-elderly trauma patients, but octogenarians have shorter LOS (length of stay) and ICU stays. This is thought to be due to the higher mortality rate in this subset of patients. Octogenarians more commonly were discharged to skilled nursing facilities than their younger counterparts in the elderly trauma population, and also had worse functional outcomes. Functional independence in feeding and social interactions appears to be preserved in octogenarians even after moderate injury severity.
Elderly patients may have subtle, unappreciated, pre-existing volume deficits due to medications they may be taking, such as those for chronic diuretic therapy or malnutrition. Medications may prevent an increase in the heart rate in response to blood loss. Pacemaker devices also may obscure rate and rhythm changes. The therapeutic range for volume resuscitation is extremely narrow for the elderly patient; therefore, aggressive hemodynamic monitoring may play an important role in successful resuscitation.
Injury research has generally concentrated on the population of patients in which that research is considered to have the most potential impact. Injury is known to be the leading cause of death in the first four decades of life. As a result, less research attention has been paid to the study of the impact of injury on elderly (> 65 years of age) individuals. However, injury is the ninth leading cause of death in elderly patients and the elderly population continues to increase dramatically in the United States. This has resulted in more elderly trauma patients being treated by trauma centers across the country.
Census data have documented this increase in the elderly population in the United States. Between 1980 and 1990, the elderly population increased to 12% of the population. This number is expected to rise to 20% by the year 2050. Similarly, injury admissions among the elderly have increased noticeably over the same time period, representing 23% of all admissions to trauma services; this number is projected to increase to 40% by the year 2050. Falls represent the most common mechanism of injury seen in elderly patients presenting to trauma centers; however, motor vehicle crashes are increasingly representing the next most frequent category. (See Figure 1.) In contrast to the younger population of trauma patients, elderly women are injured more frequently than men.
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Lack of research most likely has negatively impacted the experience of the elder patient who has been injured. There are specific areas of care for the elder injured patient that remain undefined. There is a lack of accurate guidelines for trauma center transfer for the injured elderly, beyond a general recommendation that is based on age greater than 65 years. Beginning resuscitation treatment upon presentation to the emergency department is standardized and not age specific.
There is a lack of recognition of the unique resources geriatric specialists can provide in the early care of the injured elderly, and of the impact this may have on subsequent care or outcomes. Two particular problems that occur in injured elder patients as a result of admission to the intensive care unit (ICU) or floor, new-onset disorientation and multisystem organ dysfunction, have not been adequately addressed by health care providers. There is a critical need for the health care team to collaborate to optimize elder trauma care throughout a patient's hospitalization, with the goal of returning patients to independent function in as short a time as possible, to preserve quality of life, and to respect and honor end-of-life decisions in this group of patients.
Therefore, the objectives of this article are to: describe age-specific aspects of injury management, including triage decisions and ED resuscitation specifics; characterize the outcomes risk profile for the injured elderly; and identify the specific risks that may be encountered with the elderly patient who has been injured and requires ICU or in-patient care.
Overview
In 1793, Edward Wigglesworth published the first life table for the young United States. At that time, he calculated the life expectancy from birth in New England to be a mere 35 years.2 Since that time, the life expectancy has steadily increased due to multiple improvements within the health and social sectors. (See Figure 2.)2,3 Older adults have successfully taken advantage of the additional years of their lives by maintaining active lifestyles. However, increased life expectancy may be viewed as a double-edged sword, composed not only of increased activity, but also of the risk for increased trauma.
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According to the 2006 National Vital Statistics Report, unintentional injuries are the ninth leading cause of death in adults over 65 years of age.4 Falls are the leading cause of fatal and nonfatal trauma. (See Figure 3.) For the 1.8 million older adults who survived fall-related injuries in 2003, many were left with a fear of recurrent falls.5 Recently, motor vehicle accidents were noted as the second leading cause of fatal traumatic events for the elderly.6 (See Table 1.) Pedestrian-automobile accidents are the seventh most frequent cause of geriatric trauma mortality and are especially lethal, with a greater than 50% fatality rate.7
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Despite the recognition of the scope of geriatric trauma, little is known regarding effective treatment. Organizations such as the Eastern Association for the Surgery of Trauma8 have attempted to fill this gap. Yet lack of definitive, age specific protocols remains and may be responsible for the continuing under-triage of elderly trauma patients.9 Much work remains to be done to ensure that these vulnerable members of our society are provided with optimal specialized care.
The concept that the elderly are not simply older adults is paramount when first discussing their treatment following a traumatic injury. The aging process alters the physiology of multiple organ systems. For example, cardiac output and the ability of the heart rate to increase in response to stress diminishes. Pulmonary, neurologic, and renal functions also decrease. Loss of structural components of bone is seen with aging.10 These modifications that are caused by age may contribute not only to the mechanism of injury, but also to the presentation of the patient, as well as their subsequent care, and outcome.
The body's capability to mount an immune response to injury and heal traumatic wounds is hampered with increasing age, although many now believe the quality of the end result of healing is unchanged.11 Recent studies have indicated that age alone is a predictor of delayed wound repair, even when comorbid conditions and medications that could further exacerbate the problem are excluded.12 Factors that contribute to this slow down include delayed infiltration of inflammatory mediators, such as lymphocytes, and delayed production and deposition of collagen. A decrease in the overall strength of the healing wound, as well as the increased risk of infection seen with the decreased healing rates, complicates an already difficult recovery period for the elderly patient.11 To date, many therapeutic interventions, such as hormonal and growth factor treatments and exercise, have been investigated through animal and human studies in order to discover avenues that may enhance would healing in the elderly.13,14 However, lack of a universally accepted treatment for improving wound repair in the elderly continues. The impaired healing response that is attributable to aging presents a complex picture to those who care for the injured elder following a hospital admission.
In addition to advancing age, co-morbid medical conditions play a role in the outcome of geriatric trauma. Common chronic diseases seen in these patients include congestive heart failure, chronic obstructive pulmonary disease (COPD), and diabetes.7 Richmond and colleagues reported that risks for experiencing complications following injury are increased three-fold due to the presence of co-morbid disease.15 These factors lead to what has been termed the grim triad: advanced age + co-morbid disease + moderate injury, which may lead to loss of function and death for the injured elderly.16 The importance of recognizing and addressing these components in the management of geriatric patients cannot be overstated.
Caring for victims of trauma is typically divided into three components: triage, transport, and treatment. Special considerations, including those previously mentioned, must be incorporated into this decision-making process by health care personnel caring for elderly patients. Each step in geriatric trauma care will be discussed with the aid of previously performed research and clinical experience. By outlining a more concise protocol for managing these special patients, it is hoped that more timely and age-specific care will be delivered to the injured elderly that may aid their faster return to active lifestyles.
Triage
Under-triage. The first element of elder trauma care, triage, has historically been the first pitfall to obtaining a positive outcome. Despite disproportionately higher levels of mortality when compared with their younger counterparts,17 geriatric trauma patients are under-triaged 80% of the time.18 It is suspected that this is partially a result of the discrepancy that can exist between triage classifications and the actual severity of the injury. Physiologic parameters and injury mechanisms typically are utilized in the triage setting. However, the physiologic alterations that accompany aging, coupled with apparently minor causes of injury, may lead to lower estimations of the seriousness of the elderly patient's condition. Lack of early identification of a potentially serious injury can lead to a tragic outcome.
Under-triage also may result from lack of compliance when applying triage protocols to geriatric patients.19 It is unclear whether this is attributable to a bias that exists to consideration of aggressive management. Studies have shown that more than 50% of trauma patients ages 65-79 are discharged home, and that 20% are discharged to rehabilitation facilities. Even patients older than age 80 largely maintain their ability to independently feed themselves and interact with others following a traumatic event.1 Thus, old age should not be used as an independent factor for deciding against trauma center treatment.
Age as Guideline for Triage. Conversely, age has been adopted as a guideline for triage to a high-level trauma center. Demetriades and researchers found that 75% of patients older than age 70 did not meet trauma team activation criteria upon presentation. Due to the high mortality in this age group, it was suggested that age older than 70 years be added to the existing trauma triage protocol.20 Other centers have adopted an age older than 55 to be a consideration for transport to a trauma center.19 When determining whether or not age should be a predominant factor in triage decisions, overtriage may be an economic and resource concern. Nevertheless, it is clear that the potential hazards of under-triage in the elderly mandate age to be included in the criteria for triage to a trauma center.
Identify Need and Correctly Triage. Identifying the level of need and correctly triaging elderly trauma patients is the crucial first component of providing appropriate care. Due to the multiple unique characteristics presented by these patients, triage personnel should adopt the following considerations when making decisions regarding subsequent treatment.
First, physiologic parameters, such as heart rate, may appear "normal" despite significant injury as a result of the lack of physiologic reserve that accompanies aging. Similarly, a normal blood pressure may portend hemodynamic instability for a population that frequently struggles with hypertension. In addition, the potential for complications substantially increases with the presence of co-morbidities. Thus, every effort should be made to obtain as thorough a preliminary medical history as possible. Finally, advanced age increases mortality risk but does not independently predict whether aggressive treatment will be futile. Age has not been shown to have an association with inhospital mortality. Of patients older than age 55 who are eventually found to require a trauma center, only 29% initially met criteria for the trauma center care they need;18 it is, therefore, recommended that age greater than 55 be included in the decision to triage patients to trauma centers. Physiologic age, co-morbid conditions, and chronologic age should be constituents of the decision to triage these patients to levels I or II trauma centers.21 Milzman and colleagues, in a study of nearly 8000 trauma patients, noted a three-fold increase in trauma mortality in patients with pre-existing conditions.21
Transport
Method of Transport and Location Decisions. The complexities which have confounded the issue of adequately triaging geriatric trauma patients continue into the sphere of patient transport. Ensuring that these patients arrive at centers that are equipped to handle their distinctive needs begins with their method of transfer. Typically, patients utilize either EMS or personal modes of transportation. Upon arrival to the emergency department, a trauma team may or may not be alerted based upon EMS or emergency physician evaluation. While a patient's self-transport is obviously not a decision with which medical personnel are involved, those who first examine such a patient must be cognizant of the fact that their treatment has already been delayed. Such a delay may place additional strain on an already frail condition.
The decision to transport an elderly trauma patient to a trauma center versus an acute care hospital may mean the difference between life and death in certain situations. Meldon and colleagues found that for trauma victims older than age 80, transfer to a nontrauma center resulted in higher-than-predicted levels of mortality.19 Scalea has reported that early aggressive cardiovascular monitoring can reduce mortality by 50%.22 Aggressive treatment at a trauma center has been found to be an independent variable determining a patient's chance of survival.
Initial Response. Initial responders to elderly trauma patients must take into account physiologic and chronologic age when aiding in transport, which is reminiscent of the factors which play a role in triage. Vital signs within accepted limits actually may mask hemodynamic instability due to altered physiology. Treatment at acute care hospitals and delays in trauma team activation and assessment increase the risk for mortality in the elderly. Age greater than 55 years old and physiologic considerations should alert emergency responders to the potential need for timely transport to a high-level trauma center.
Amid triage and transport decisions, first-responders also commence the third step in the management of geriatric trauma victims: treatment. Currently, there is little information available which specifically addresses the treatment of geriatric trauma patients. With elderly patients comprising up to 39% of EMS runs,23 it is essential to recognize the need for an age-appropriate resuscitation and treatment protocol that would aid emergency responders with their initiation of treatment. This paper will examine the standard trauma care protocols that have been utilized, along with special considerations of presentation and response to treatment in elderly patients.
Gaining Details of Trauma. Pre-hospital providers have the unique advantage of assessing patients at the scene of the injury event. Witnesses to the trauma and the trauma environment itself can both provide valuable information to emergency responders who are trying to piece together details regarding the mechanism of injury. Every opportunity must be taken to gather as much data as possible regarding the trauma itself so that the patient's injuries can be better understood and treated.24 This also would include collecting information on the patient's past medical history and medication usage, which will better aid in the triage and transport decisions previously discussed.
Possible Elder Abuse. In addition to gathering information regarding the trauma incident itself, first-responders must be vigilant for signs of elder abuse. According to the 2004 Survey of State Adult Protective Services, 253,426 incidents of elder abuse were reported in 32 responding states.25 However, it is feared that many instances go unrecognized, leading the Senate Special Committee on Aging to estimate that there are a staggering 5 million victims of elder abuse every year.26 Signs that should alert emergency responders to potential abuse include multiple bruises, burns, fractures, abrasions in various stages of healing, pressure sores, extreme withdrawal, and injury to breasts or genitalia. Neglect, whether self-imposed or at the hands of others, could present with poor hygiene, refusal to accept medical attention, poor living conditions, dehydration, or malnutrition.27 (See Table 2.) In these cases, treatment may consist not only of physically addressing wounds, but also of making the appropriate agencies aware of the situation. Attention to patterns of injury and seemingly trivial details could rescue an older adult from the nightmare of abuse.
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Beginning Trauma Care. The ABCs of trauma care should be provided to geriatric patients starting in the field and be continuously monitored. Confirming or securing an adequate airway and maintaining breathing are the first concerns. Ill-fitting dentures or macroglossia are just two of the conditions seen in the elderly that may precipitate airway obstruction.28 Intubation also may be more challenging due to cervical arthritis and friable nasopharyngeal tissues. Patients with multiple traumatic injuries, decreased neurologic function (Glasgow Coma Scale [GCS] score < 8), cardiac arrest, hypoxemia, or airway obstruction should be immediately intubated.29 Supplemental oxygen should be administered to elderly trauma patients due to their poor tolerance of hypoxia, with special care not to cause respiratory depression in patients with COPD.7
We have already noted how circulatory status may be difficult to determine in geriatric patients due to their altered physiology. Medication regimens, such as those including beta-blockers, may add to the uncertainty of the degree of hypovolemia. Intravenous access and fluid replacement should begin during the initial pre-hospital assessment. Due to their inability to tolerate hypovolemia or fluid overload, it has been determined that boluses of 250 cc of crystalloid solution should be administered at a time, followed by examination for rales and other signs of fluid overload.22
Neurologic status and injuries also are surveyed in the pre-hospital phase of care. Pupillary size, response to pain and commands, and mental status should be determined. Admittedly, this component of the evaluation may be hindered by the presence of a concomitant disease, such as Alzheimer's. The high incidence of cervical spine injury in the elderly following blunt trauma necessitates cervical immobilization prior to arrival at the hospital.
During transport to the trauma center, emergency personnel should continue to evaluate airway, breathing, circulation, and neurologic status. Vital signs and ECG findings should be recorded in preparation for presentation in the emergency department. The patient also should be exposed for a thorough examination, with special care to prevent hypothermia.24 The care that is initiated by pre-hospital providers is the geriatric trauma patient's first chance for a positive outcome.
Initial Care in the Emergency Department (ED)
The age appropriate resuscitation protocol initiated by emergency personnel in the field is continued and expanded in the emergency department. The goals of this stage of care include stabilizing the patient and expediting their stay in the ED. Scalea has reported that an ED admission to monitoring time of 5.5 hours is associated with nearly 100% mortality figures for hemodynamically unstable patients.22 Consequently, Biffl and colleagues implemented a system at their level I trauma center that stressed the importance of quickly moving elderly patients through the emergency room to the ICU.30 The fragile nature of the geriatric trauma patient demands that definitive care be provided as soon as possible to limit deterioration.
Airway and Breathing. Airway management and breathing are the first steps in immediate resuscitation efforts following presentation of an elderly trauma patient to the ED. The potentially disastrous outcomes of hypoxemia on the cardiovascular and neurologic systems, which are only heightened with increasing age, mandate an aggressive approach. Orotracheal intubation is the preferred method for obtaining a definitive airway in all trauma patients, including elderly trauma patients; however, elderly patients may present unique challenges. Dentures, bleeding associated with anti-coagulation therapy, and the inability to adequately visualize the airway may make these individuals a "difficult airway" from the onset. Medications typically used in rapid sequence intubation protocols may have a disastrous post-procedure impact on blood pressure. Underlying cervical spinal column age-related changes may hamper the clinician's ability to even achieve a neutral position for inline immobilization.
No one should ever take the performance of orotracheal intubation lightly in the frail elderly. The most experienced physician with airway expertise should perform the intubation. Cricothyrotomy may be necessary in patients with difficult airways. This, too, may be a difficult procedure for similar reasons.
A pulse oximeter should be utilized to continually assess oxygen saturation, and supplemental oxygen must be used in elderly patients, with careful monitoring of those with COPD.31 Arterial blood gases should be drawn to further assess oxygenation status. Aggressive pulmonary resuscitation has been linked with decreased complications and mortality and is encouraged in the treatment of the injured elderly.32
Circulation. Circulatory status must be re-evaluated upon hospital admission. Pre-existing cardiac disease, poor fluid intake, and medications may complicate the presentation and response to treatment. Discrete fluid boluses should be administered intravenously, with care being given to prevent fluid overload in these patients, whose cardiac contractility has diminished with age.
Blood products may be necessary in severely hemodynamically unstable patients. A multistate study published in 2004 recognized that patients greater than 65 years of age receive the majority of blood transfusions, and that they also suffer higher mortality rates post-transfusion.33 Much work remains regarding understanding the relationship between blood products and outcomes in the elderly, yet the aggressive approach to providing volume stability in these patients is still emphasized.
Mental Status. Geriatric patients must be screened for neurologic disability during the initial hospital assessment. The key aspects of this evaluation remain as in the nonelder injured patient: the GSC score, assessment of pupils, and the specific aspects of a detailed sensory and motor examination. Underlying chronic mental status changes can have an impact on the "baseline neurological examination" and it is important to reconcile the findings of the current examination with what is known of the patient's mental status prior to injury. When in doubt, the default position is that the current findings are acute and should be aggressively researched with imaging studies, particularly in the face of anti-platelet, anti-coagulant therapy. Ocular changes may occur as a consequence of aging or surgery to treat an age-related disability.
Cervical Spine Precautions. The high prevalence of cervical spine injuries in elderly patients, even following seemingly minor trauma, mandates a thorough examination and spinal precautions. Studies have shown that patients with no posterior midline cervical tenderness on palpation, no focal neurological abnormalities, no potentially distracting painful injury, no intoxication, and who are fully awake, alert, and oriented may have their cervical spine cleared clinically.34 It is incredibly difficult to apply this algorithm to the elderly, however.
Imaging Modalities. Age-related changes noted on routine imaging studies essentially mandate a more definitive evaluation. Plain radiographs, computerized tomography (CT) scans, or magnetic resonance imaging (MRI) should be used to further investigate positive or questionable clinical characteristics, with MRIs being the most sensitive for detection of a ligamentous injury.29 The remainder of the spine may be cleared with CT scanning; this should be completed as soon as possible after stabilizing the patient to avoid unnecessary prolonged immobilization.
Secondary Survey. As we have seen, the ABCs of initial resuscitation, while similar for all victims of trauma, must be implemented with unique considerations for elderly patients. Attention to age-related conditions and complications continues with the secondary survey. Certain labs and tests to be ordered are protocol-driven, regardless of the age of the patient. On the other hand, advanced age is an indication for increased vigilance regarding specific social and medical disabilities.
Standard Laboratory Tests. The secondary examination is performed while continually assessing ABC status and immediately addressing instabilities as they arise. Standard labs to be ordered at this time include a complete blood count, complete metabolic panel, urinalysis, prothrombin time (PT), partial thromboplastin time (PTT), and type and screen. Elderly patients with specific co-morbidities may require additional labwork.
Plain radiography of the C-spine, chest, and pelvis should be completed. An ECG typically is performed, and some believe that a pulmonary artery catheter should be placed in severely injured patients when they are in an appropriately monitored setting.35 A FAST (focused assessment by sonography for trauma) ultrasound examination should be considered in the hemodynamically unstable patient with suspected blunt abdominal trauma. Stable patients may be taken for CT scanning of the head, abdomen, and pelvis.
Along with standard evaluation protocols, social situations frequently seen in the geriatric population can drive laboratory work-up following trauma. Despite a common public misconception, the elderly population is not immune from suffering with alcoholism. Zautcke and researchers found that nearly 50% of elderly trauma patients who were evaluated for the presence of alcohol tested positive.36 Benzodiazepines and opiates were the most common drugs detected in their patients. Thus, old age should certainly not preclude the need to assess coexistent substance use in the presence of trauma.
Mechanism of Injury. Likewise, clinical suspicion should be elevated for certain mechanisms of injury in the elderly. We have already discussed the need for awareness and subsequent intervention in cases of elder abuse. Similarly, the prevalence of depression in the elderly population can be associated with trauma and must be addressed. Nearly 10% of hospitalizations involving patients older than age 65 are the result of suicide attempts.37 These patients are most likely to be Caucasian males injured with a firearm. A patient who survives such an injury, or who is suspected of having attempted suicide, should be psychiatrically evaluated following stabilization. Recognition of such a sequence of events begins during ED evaluation.
Chest Wall Injuries. Certain injuries, while potentially severe in any trauma patient, require extra surveillance to prevent consequent decline and disastrous complications in the elderly. One such injury involves the chest wall.
Patients older than age 65 who have rib fractures following trauma were found to be five times more likely to die than patients younger than age 65 who have rib fractures.38 Rib fractures also significantly increase the risk for pneumonia, which is the leading cause of hospital mortality in elderly patients.22,39 Fractured ribs may alert the physician to other accompanying underlying injuries, such as those involving the spleen, lungs, or heart. Admission to a trauma center for ventilatory support, sufficient pain control, and early mobilization are steps that should be taken in the management of geriatric patients with confirmed or suspected rib fractures.29
Head Injuries. Head injury in the elderly trauma patient may have a dramatic or an occult presentation, requiring increased suspicion by the clinician. The cerebral atrophy and decreased blood supply to the brain that typically accompany aging place the injured elder in a neurologically precarious situation. Cerebral contusions and subdural hematomas (see Figure 4) are the most frequently diagnosed head injuries resulting from falls.40 Traumatic brain injury has been associated with twice the rates of mortality for elderly patients when compared with younger patients.41 Thus, all elderly patients with suspected head trauma, regardless of severity, should undergo a head CT scan.
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Substance abuse, suicide attempts, chest wall injuries, and head trauma are just a few of the conditions that should be screened for during the emergency department comprehensive survey. Again, the goal is to complete a thorough evaluation and expeditiously move the patient to an area of definitive care. The optimal location of that definitive care has been debated, but studies have shown that ICU admission is the preferred destination for elderly trauma patients.42,43
Subsequent Care, Transition of Care, or Critical Care
There is some debate as to whether or not aggressive care is warranted in a population with a higher propensity toward mortality following injury. Demetriades and colleagues found that aggressive management concomitant with ICU admission resulted in decreased mortality and permanent disability.42 We have already seen how decisions aimed at avoiding under-triage and inadequate initial evaluation and treatment can improve outcomes in this susceptible population. Accordingly, routine admission to an ICU for continued strict monitoring is recommended for elderly trauma victims with at least a moderate injury.43
Confusion is one important complication that may arise following transfer to the ICU. Geriatric patients already suffering from the presence of dementia are at increased risk for confusion during hospitalization.44 Polypharmacy, which is highly prevalent in the elderly, can add to this condition, along with initiation of a different routine and lack of familiar surroundings.
The first step in evaluation should be to rule out potentially life-threatening causes of delirium, such as alcohol withdrawal or electrolyte abnormalities.45 Medications that are not necessary should be discontinued, and every effort should be made to control pain. Patients should be frequently re-oriented and mobilization should be encouraged as soon as possible. Restraints should be used sparingly as they may exacerbate confusion and enable skin breakdown.
The ICU stay is perhaps the most important part of geriatric trauma management in terms of achieving a positive outcome. Caring for these patients may easily appear daunting as their pre-existing comorbidities and their traumatic injuries coalesce into a complicated presentation. Very little has been written regarding this phase of treatment, but recent studies that have implemented geriatrician consultations have shown their effectiveness by improving outcomes. A team approach that utilizes experts in the fields of trauma and geriatric medicine provides the elderly patient with the best opportunity for survival and a return to their baseline function.
In 2002, Richmond and coworkers suggested that the comprehensive care offered by a geriatric consultation service could be an invaluable addition to a trauma team caring for geriatric patients.46 Fallon and colleagues instituted the concept of a Geriatric Trauma Team (GTT), which included geriatricians and advanced practice nurses who collaborated with the trauma surgical team, physical therapists, and social workers in the management of trauma patients older than age 65.16 The geriatricians were able to advise in areas related to pain control, delirium, rehabilitation, and hypertension. Those patients who were seen by the GTT had a lower incidence of mortality compared with those who were not seen (5% versus 31%), as well as an increased ability to return to independent living. It was felt that patients who were not seen, yet returned to independent functioning, represented patients with higher physiologic reserve and less comorbidities than their age would suggest. Patients evaluated by the GTT had physiologic characteristics that mirrored chronologic age. Those who were not seen and succumbed to their injuries represented patients with severe physiologic decline or excessive comorbid disease. It was determined that the GTT was successfully able to address age-specific physical conditions in the elderly, while also providing advice concerning emotional and social factors. The value of this service was evident by the fact that GTT recommendations were followed 91% of the time.
The goal of the GTT is to appropriately manage pre-existing disease in the wake of traumatic injury. Suggestions were also made that would limit the impact of the ICU environment on the patient's mental status, as well as propose treatments to maximize the potential for a return to previous functioning. In light of the promise evidenced by the GTT study, it is recommended that consulting a geriatrician be a mandatory part of the comprehensive hospital care of elderly trauma patients.
Summary
The triage, transport, and treatment of the older adult suffering from a traumatic injury should be driven by age appropriate assessment protocols that have been developed to attend to the unique considerations found in the elderly. The recommendations made in this review reflect these efforts. However, the need for further research in the field of geriatric trauma is evidenced by the relatively sparse information that is currently available. The need is amplified with the realization that, according to the United States Census Bureau, those who are 65 years of age and older will account for roughly 20% of the total population in 2050.47 Therefore, management of these patients should be taught in residency in order for the increased incidence of elderly trauma victims to be met with an increased number of prepared medical personnel.
The "grim triad" of chronological age, co-morbid disease, and moderate injury cannot be altered by trauma responders. Nevertheless, timely and aggressive decisions starting in the field can decrease mortality and improve overall function following discharge.
Proper care of the injured elder is a team effort and should include everyone from emergency providers to trauma surgeons to geriatricians. As work continues to better outline geriatric trauma management strategies, the goal is to maximize the quality of life for these active yet vulnerable members of society. The anticipated future of trauma demands these efforts, and these valuable patients deserve no less.
References
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Prompt, accurate assessment of the severity of injury and early initiation of appropriate critical care — including adequate oxygenation, ventilation and correction of hypotension — is of crucial importance in preventing deaths in children with severe trauma. This article reviews the critical aspects of airway assessment and management in the pediatric trauma patient.Subscribe Now for Access
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